Payment by results can mean ambulances waiting outside hospitals until patients can be treated within a target time. Photograph: David Levene for the Guardian

Payment by results is a simple idea: people and organisations should only get paid for what they deliver. Who could argue with that? If your job is to get people back to work, then find them a job dammit.

Plenty of people working in local government and public services are already starting to realise this is nonsense, and a pernicious, damaging nonsense at that. The evidence is very clear: if you pay (or otherwise manage performance) based on a set of pre-defined results, it creates poorer services for those most in need. It is the vulnerable, the marginalised, the disadvantaged who suffer most from payment by results.

Here's why: payment by results does not reward organisations for supporting people to achieve what they need; it rewards organisations for producing data about targets; it rewards organisations for the fictions their staff are able to invent about what they have achieved; it pays people for porkies.

We know that common things happen when people use payment by results, and other outcomes-based performance management systems. There have been numerous studies that show that such systems distort organisational priorities and make organisations focus on doing the wrong things – and they make people lie.

This lying takes all sorts of different forms. Some of them are subtle forms of deception: teachers who teach to the test or who only enter pupils for exams they know they are going to pass; employment support that helps only those likely to get a job and ignores those most in need; or hospitals that reclassify trolleys as beds, and keep people waiting in ambulances on the hospital doorstep until they know they can be seen within a target time. In the literature, this is known as gaming the system.

Some of the lying is less subtle. People just make up results. Last year'sscandal with A4e provision of employment programmes is just one in a long line of haphazard outcome measurement.

Sadly, the distortion of practice by payment by results doesn't just stop with managers. The evidence shows that it also undermines the practice of frontline workers. It turns the relationship between support worker and client upside down. When payment-by-results practices are introduced, workers who used to ask their clients "How can I help you to achieve what you need?" instead think "How can you help me to produce the data I need?"

Spending time alongside social workers, such as Ryan, who works with Ella's son Tom, we saw that 86% of time is system driven – filling in forms for accountability and discussing them with colleagues. Most shockingly, even the 14% of time spent face to face with a family member is not developmental. The dialogue between Ryan and Tom is dictated by the forms and their need for data and information. This squeezes out any possibility of the sort of conversation that might be needed to develop a supportive relationship as a first step in fostering change.

There's a growing momentum behind the understanding that outcomes-based performance management in general – and payment by results, in particular – is dangerous idiocy. It makes good people do the wrong things, and then forces them to lie about it.

I will be taking part in a public conversation with others who are asking questions about payment by results, and seeking alternatives to outcomes-based performance management at a conference in Manchester on Wednesday 6 March. If you've been forced into gaming the system or just plain telling porkies in order to meet daft results targets, I'd love to hear your stories. If you get it off your chest you help contribute to changing the system. Let's make this change; it's important.

Toby Lowe is a visiting fellow at Newcastle University business school and chief executive of Helix Arts, a charity that transforms lives through art. You can follow him on Twitter: @tobyjlowe

2015 Report

What did we achieve?

Credit: Tagaza Djibo/UNESCO

The 2015 Education for All Global Monitoring Report will review how much the Education for All (EFA) movement, revitalized at the World Education Forum in Dakar in 2000, has contributed to ensuring that all children, young people and adults enjoy their right to a quality education that meets their basic learning needs.

The Report will provide a definitive global assessment of overall progress toward the six EFA goals established at the WEF, paying particular attention to gaps between those who benefited and those who did not.

This assessment will also provide lessons for the framing of post-2015 education goals and strategies.

By PHILIP M. BOFFEYJULY 30, 2014,The New York Times

For Michele Leonhart, the administrator of the Drug Enforcement Administration, there is no difference between the health effects of marijuana and those of any other illegal drug. “All illegal drugs are bad for people,” she told Congress in 2012, refusing to say whether crack, methamphetamines or prescription painkillers are more addictive or physically harmful than marijuana.

Her testimony neatly illustrates the vast gap between antiquated federal law enforcement policies and the clear consensus of science that marijuana is far less harmful to human health than most other banned drugs and is less dangerous than the highly addictive but perfectly legal substances known as alcohol and tobacco. Marijuana cannot lead to a fatal overdose. There is little evidence that it causes cancer. Its addictive properties, while present, are low, and the myth that it leads users to more powerful drugs has long since been disproved.

That doesn’t mean marijuana is harmless; in fact, the potency of current strains may shock those who haven’t tried it for decades, particularly when ingested as food. It can produce a serious dependency, and constant use would interfere with job and school performance. It needs to be kept out of the hands of minors. But, on balance, its downsides are not reasons to impose criminal penalties on its possession, particularly not in a society that permits nicotine use and celebrates drinking.

An Institute of Medicine study found dependency rates for marijuana were far lower than those for other substances.

PERCENT

OF GENERAL

POPULATION

WHO HAD

EVER USED:

OF THOSE USERS, PERCENT WHO EVER

BECAME DEPENDENT ON THE DRUG:

Tobacco

Heroin

Cocaine

Alcohol

Anti-anxiety drugs

Marijuana

76

2

16

92

13

46

%

32%

23

17

15

9

9

Source: Institute of Medicine, 1999

Marijuana’s negative health effects are arguments for the same strong regulation that has been effective in curbing abuse of legal substances. Science and government have learned a great deal, for example, about how to keep alcohol out of the hands of minors. Mandatory underage drinking laws and effective marketing campaigns have reduced underage alcohol use to 24.8 percent in 2011, compared with 33.4 percent in 1991. Cigarette use among high school students is at its lowest point ever, largely thanks to tobacco taxes and growing municipal smoking limits. There is already some early evidence that regulation would alsohelp combat teen marijuana use, which fell after Colorado began broadly regulating medical marijuana in 2010.

Comparing the DangersAs with other recreational substances, marijuana’s health effects depend on the frequency of use, the potency and amount of marijuana consumed, and the age of the consumer. Casual use by adults poses little or no risk for healthy people. Its effects are mostly euphoric and mild, whereas alcohol turns some drinkers into barroom brawlers, domestic abusers or maniacs behind the wheel.

An independent scientific committee in Britain compared 20 drugs in 2010 for the harms they caused to individual users and to society as a whole through crime, family breakdown, absenteeism, and other social ills. Adding up all the damage, the panel estimated that alcohol was the most harmful drug, followed by heroin and crack cocaine. Marijuana ranked eighth, having slightly more than one-fourth the harm of alcohol.

Federal scientists say that the damage caused by alcohol and tobacco is higher because they are legally available; if marijuana were legally and easily obtainable, they say, the number of people suffering harm would rise. However, a 1995 study for the World Health Organization concluded that even if usage of marijuana increased to the levels of alcohol and tobacco, it would be unlikely to produce public health effects approaching those of alcohol and tobacco in Western societies.

Most of the risks of marijuana use are “small to moderate in size,” the study said. “In aggregate, they are unlikely to produce public health problems comparable in scale to those currently produced by alcohol and tobacco.”

While tobacco causes cancer, and alcohol abuse can lead to cirrhosis, no clear causal connection between marijuana and a deadly disease has been made. Experts at the National Institute on Drug Abuse, the scientific arm of the federal anti-drug campaign, published a review of the adverse health effects of marijuana in June that pointed to a few disease risks but was remarkably frank in acknowledging widespread uncertainties. Though the authors believed that legalization would expose more people to health hazards, they said the link to lung cancer is “unclear,” and that it is lower than the risk of smoking tobacco.

The very heaviest users can experience symptoms of bronchitis, such as wheezing and coughing, but moderate smoking poses little risk. A 2012 study found that smoking a joint a day for seven years was not associated with adverse effects on pulmonary function. Experts say that marijuana increases the heart rate and the volume of blood pumped by the heart, but that poses a risk mostly to older users who already have cardiac or other health problems.

How Addictive Is Marijuana?Marijuana isn’t addictive in the same sense as heroin, from which withdrawal is an agonizing, physical ordeal. But it can interact with pleasure centers in the brain and can create a strong sense of psychological dependence that addiction experts say can be very difficult to break. Heavy users may find they need to take larger and larger doses to get the effects they want. When they try to stop, some get withdrawal symptoms such as irritability, sleeping difficulties and anxiety that are usually described as relatively mild.

The American Society of Addiction Medicine, the largest association of physicians specializing in addiction, issued a white paper in 2012 opposing legalization because “marijuana is not a safe and harmless substance” and marijuana addiction “is a significant health problem.”

Nonetheless, that health problem is far less significant than for other substances, legal and illegal. The Institute of Medicine, the health arm of the National Academy of Sciences, said in a 1999 study that 32 percent of tobacco users become dependent, as do 23 percent of heroin users, 17 percent of cocaine users, and 15 percent of alcohol drinkers. But only 9 percent of marijuana users develop a dependence.

“Although few marijuana users develop dependence, some do,” according to the study. “But they appear to be less likely to do so than users of other drugs (including alcohol and nicotine), and marijuana dependence appears to be less severe than dependence on other drugs.”

There’s no need to ban a substance that has less than a third of the addictive potential of cigarettes, but state governments can discourage heavy use through taxes and education campaigns and help provide treatment for those who wish to quit.

Impact on Young PeopleOne of the favorite arguments of legalization opponents is that marijuana is the pathway to more dangerous drugs. But a wide variety of researchers have found no causal factor pushing users up the ladder of harm. While 111 million Americans have tried marijuana, only a third of that number have tried cocaine, and only 4 percent heroin. People who try marijuana are more likely than the general population to try other drugs, but that doesn’t mean marijuana prompted them to do so.

Marijuana “does not appear to be a gateway drug to the extent that it is the cause or even that it is the most significant predictor of serious drug abuse,” the Institute of Medicine study said. The real gateway drugs are tobacco and alcohol, which young people turn to first before trying marijuana.

It’s clear, though, that marijuana is now far too easy for minors to obtain, which remains a significant problem. The brain undergoes active development until about age 21, and there is evidence that young people are more vulnerable to the adverse effects of marijuana.

A long-term study based in New Zealand, published in 2012, found that people who began smoking heavily in their teens and continued into adulthood lost an average of eight I.Q. points by age 38 that could not be fully restored. A Canadianstudy published in 2002 also found an I.Q. loss among heavy school-age users who smoked at least five joints a week.

The case is not completely settled. The New Zealand study was challenged by a Norwegian researcher who said socio-economic factors may have played a role in the I.Q. loss. But the recent review by experts at the National Institute on Drug Abuse concluded that adults who smoked heavily in adolescence had impaired neural connections that interfered with the functioning of their brains. Early and frequent marijuana use has also been associated with poor grades, apathy and dropping out of school, but it is unclear whether consumption triggered the poor grades.

Restricting marijuana to adults is more important now that Colorado merchants are selling THC, the drug’s active ingredient, in candy bars, cookies and other edible forms likely to appeal to minors. Experience in Colorado has shown that people can quickly ingest large amounts of THC that way, which can produce frightening hallucinations.

Although marijuana use had been declining among high school students for more than a decade, in recent years it has started to climb, in contrast to continuing declines in cigarette smoking and alcohol use. Emergency room visits listing marijuana as the principal cause of admission soared above 455,000 in 2011, up 52 percent from 2004. Nearly 70 percent of the teenagers in residential substance-abuse programs run by Phoenix House, which operates drug and alcohol treatment centers in 10 states, listed marijuana as their primary problem.

Those are challenges for regulators in any state that chooses to legalize marijuana. But they are familiar challenges, and they will become easier for governments to deal with once more of them bring legal marijuana under tight regulation.